Women–Focused Treatment Agencies and Process Improvement: Strategies to Increase Client Engagement

Behavioral health treatment agencies often struggle to keep clients engaged in treatment. Women clients often have additional factors such as family responsibilities, financial difficulties, or abuse histories that provide extra challenges to remaining in care. As part of a national initiative, four women-focused drug treatment agencies used process improvement to address treatment engagement. Interviews and focus groups with staff assessed the nature and extent of interventions. Women-focused drug treatment agencies selected relational-based interventions to engage clients in treatment and improved four-week treatment retention from 66% to 76%. Process improvement interventions in women-focused treatment may be useful to improve engagement.     

Therapeutic Passion in the Countertransference

The place of the analyst's “influence” in psychoanalytic theory and practice is explored. There is a current in the literature in which it is welcomed as an aspect of “corrective experience,” although usually legitimized by being forced into the narrow channel of interpretation and understanding. A taboo on influence persists despite theoretical shifts that would seem to clear the way for greater acceptance of its importance. Among other factors, the aversion to influence is traced to its association with hypnotic “suggestion,” which implies little room for the patient's autonomy. Opening the door to embracing the possibility of influence goes hand in hand with, on one hand, the analyst respecting the patient as a competent free agent and, on the other hand, the analyst combining willingness to take a stand with willingness to reflect critically on his or her participation. In that context, and with those caveats, the analyst takes on the responsibility to combat destructive introjects and to become an inspiring, affirmative presence in the patient's life. The analyst's passion for the patient's well-being and for changes that entail the realization of dormant potentials now has its place. Different kinds of expression of therapeutic passion in the countertransference are described and illustrated.     

Response to Layton: Considering the Sociopolitical Context of Dialectical Constructivism

What is commonly missing from psychoanalytic formulations, including my own, that Lynne Layton rightfully challenges us to correct is the locating of the possible dysfunctionality of the individual and the family within the context, not just of a brutally indifferent universe but also of an arguably brutally indifferent economic, political, and institutional environment. I differ with Layton in that I am more prepared to consider possible universals that bear on human experience and moral standards. For example, I would say that “reflection on the foundations of knowledge” trumps nonreflective fundamentalist thinking in capturing the best attitude to assume towards pursuit of truth. Also, the universality of the human tendency to deny death may underlie many diverse cultural belief systems. Nevertheless, Layton challenges us to reflect on how conventional psychoanalytic practices may collude with aspects of our own culture we would do well to try to combat, in ourselves and in our patients, through owning and proactively exercising our moral influence.     

At Death's Door: Therapists and Patients as Agents

This paper explores the interrelationship between patients' exercise of will to make advances in an analysis and their readiness to forgive their analysts for their human limitations. There is a thin line between idealization of the analyst, probably a necessary component of the process, and resentment of the analyst for his or her privileged position in the world and in the analytic situation itself. The patient's “progress” emerges as a kind of reparative gift, one that implicitly overcomes the patient's tendency to withhold such change out a sense of chronic, malignant envy. Particularly poignant in terms of its potential to elicit the patient's reparative concern is the situation in which the analyst is struggling with his or her mortality because of aging or life-threatening illness. In this essay two clinical vignettes are presented to illustrate some of the issues that this situation poses. One begins with an elderly patient appearing at the door of the analyst's (the author's) home the day of his return from the hospital after coronary bypass surgery. The other begins with an analyst who is terminally ill appearing at the door of a patient who is threatening suicide. The two stories are compared in terms of their implications for human agency, the exercise of will, and the coconstruction of meaning in the face of mortality in the analytic process.     

Pediatric Sub-specialist Controversies in the Treatment of Congenital Heart Disease in Trisomy 13 or 18

Trisomy 13 and 18 are associated with congenital heart disease. Cardiac palliation has been reported in the literature, but is not usually done in this population. Thus, a multi-disciplinary team may experience controversy in formulating a care plan that includes cardiac intervention. Our objective was to determine differences in recommendations for cardiac intervention in this population between physicians specializing in pediatric cardiac critical care, neonatology, and genetics. A web-based survey was performed between April 2007 and August 2008. This survey evaluated surgical and transcatheter cardiac palliations that had been performed for individuals with trisomy 13 or 18 at the respondent’s institution, the respondent’s recommendations for cardiac intervention in hypothetical symptomatic patients with trisomy 13 or trisomy 18 and the influence of parental preference on these recommendations. Eight hundred fifty-nine responses were obtained from a primarily academic practice setting (59%). Cardiologists were most likely to recommend intervention; low risk interventions were recommended by 32% of cardiologists, 7% of neonatologists and 20% of geneticists. Parental request to intervene resulted in a 3 fold increased in the likelihood of all specialist recommending intervention. Counseling of families frequently occurred by multiple sub specialists (50%) and there was frequently (71%) a difference in opinion. Individuals with trisomy 13 or 18 are receiving cardiac intervention at many institutions. Cardiologists were more likely than geneticists or neonatologists to recommend intervention on all heart lesions other than single ventricle palliation which no specialists recommended. Parental wishes that “everything be done” significantly influenced all specialists’ recommendations.     

Representation of unattended material in memory

The current study addresses how information whose processing was not part of task requirement (unattended) is represented in memory. Using a novel measure, recognition memory for unattended material was assessed twice, once when it appeared with the same (old) attended study target and once with a new target. The data reveal memory for unattended study information only in the old target condition. Results suggest that the entire study event is encoded and represented in a memory trace, which contains both attended target information along with unattended context information. In conclusion, manifestation of unattended memory may be dependent on the presence of old target information at test.     

Attenuated response to methamphetamine sensitization and deficits in motor learning and memory after selective deletion of β-catenin in dopamine neurons

In the present study, we analyzed mice with a targeted deletion of β-catenin in DA neurons (DA-βcat KO mice) to address the functional significance of this molecule in the shaping of synaptic responses associated with motor learning and following exposure to drugs of abuse. Relative to controls, DA-βcat KO mice showed significant deficits in their ability to form long-term memories and displayed reduced expression of methamphetamine-induced behavioral sensitization after subsequent challenge doses with this drug, suggesting that motor learning and drug-induced learning plasticity are altered in these mice. Morphological analyses showed no changes in the number or distribution of tyrosine hydroxylase-labeled neurons in the ventral midbrain. While electrochemical measurements in the striatum determined no changes in acute DA release and uptake, a small but significant decrease in DA release was detected in mutant animals after prolonged repetitive stimulation, suggesting a possible deficit in the DA neurotransmitter vesicle reserve pool. However, electron microscopy analyses did not reveal significant differences in the content of synaptic vesicles per terminal, and striatal DA levels were unchanged in DA-βcat KO animals. In contrast, striatal mRNA levels for several markers known to regulate synaptic plasticity and DA neurotransmission were altered in DA-βcat KO mice. This study demonstrates that ablation of β-catenin in DA neurons leads to alterations of motor and reward-associated memories and to adaptations of the DA neurotransmitter system and suggests that β-catenin signaling in DA neurons is required to facilitate the synaptic remodeling underlying the consolidation of long-term memories.